Community Ophthalmology Notes and Report

→>>>>>>>>>>>>>>>>>>>>>>>>>> Ophthalmic Assessment / Clinical Notes <<<<<<<<<<<<<<<<<<<<<<<<<<< Presentation & Details: - Reason for Visit: [Brief description of the reason for the visit] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - History of symptoms / Signs: [Description of onset, duration, severity, and character of the visual complaint] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Past Ocular History: [History of eye diseases, surgeries, treatments, and outcomes] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Medical History: [Relevant ocular and systemic conditions] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Medication: [Current ocular and systemic medications] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Allergies: [All allergies reported] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Family Ocular History: [Relevant family history of eye diseases] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Social History: [Relevant social factors such as driving status and occupational hazards] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) Diagnostic Tests: - Visual Acuity: [Visual acuity with and without correction for RE and LE] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Intraocular Pressure: [Measurement method and values for RE and LE] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Central Corneal Thickness: [CCT measurements for RE and LE] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Visual Fields: [Summary of visual field results] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - OCT: [Summary of OCT findings] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Topography / DNEye / Other: [Summary of other diagnostic scan results] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) Assessment: - Anterior Segment: [Findings from slit-lamp examination of the anterior segment] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Posterior Segment: [Findings from dilated fundus examination] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) Diagnosis: - [Diagnosis stated by the clinician] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely. Do not infer or assume a diagnosis.) Treatments: - [Medications, laser treatments, or surgical interventions planned] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) Plan: - Follow-Up: [Interval until next visit and conditions for earlier return] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Patient Education: [Information provided about diagnosis, treatment, prognosis] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Referrals: [Referrals to other specialists or services] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) --- →>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> _Start of Clinic Letter_ <<<<<<<<<<<<<<<<<<<<<<<<<<< - Referred from: [Description of referral source, such as GP, optometrist, or self-referral] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Reason for Visit: [Brief description of the reason for the visit] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Visual Acuity: [Values with and without correction for RE and LE] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Intraocular Pressure: [Measurement method and values for RE and LE] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) **Diagnosis:** - [Diagnosis stated by the clinician] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely. Do not infer or assume a diagnosis.) **Treatment:** - [Planned medications, laser treatments, or surgical interventions] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) **Review Plan:** - Follow-Up: [Interval until next visit, earlier review indicators, or discharge instructions] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - Referrals: [Referrals to specialists if needed] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) Action for GP: [Actions requested or FYI information for the GP] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) →>>>>>>>>>>>>>>>>>>>>>>>>>>> End_ of Clinic Letter_ <<<<<<<<<<<<<<<<<<<<<<<<<<< For Admin / Secretarial Colleagues: [Administrative instructions such as sending reports, completing pro-formas, or initiating referrals] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) (Never come up with your own patient details, assessment, diagnosis, differential diagnosis, plan, interventions, evaluation, or plan for continuing care — use only the transcript, contextual notes, or clinical note as a reference. If any information related to a placeholder has not been explicitly mentioned, do not state that it is missing; simply omit the placeholder or leave it blank. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information.)